How to Push the Limit: Developing Informed Research and Implementation Programs in Resource-Limited Settings.
How to Push the Limit: Developing Informed Research and Implementation Programs in Resource-Limited Settings.
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如何突破极限：在资源有限的环境中制定知情研究和实施计划。
DOI：
10.1097/pcc.0000000000001565
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发表时间：
2018
期刊：
影响因子：
--
通讯作者：
Doctor,Allan
中科院分区：
文献类型：
--
作者：
Muttalib,Fiona;Doctor,Allan
在低收入和中等收入国家，儿童意外伤害发生率很高，伤害造成的死亡率是高收入国家的3.4倍(1)。儿童创伤性脑损伤(TBI)仍然是一个严重的全球健康问题，全世界每年有多达300万儿童受到影响，死亡率在1%至7%之间(2)。颅脑损伤是最常见的严重损伤之一，尽管在目前的文献中描述不足，在LMICs中可能被低估[1]。迄今为止最大的定性文献综述包括165,000名患有脑外伤的儿童，但这一群体只包括127名来自LMIC的儿童(一份来自非洲，三份来自亚洲)(2)。在本期《儿科重症护理医学》中，Fink等人(3)部分解决了现有流行病学数据的匮乏问题，目的是为未来的研究、教育和质量改进提供优先事项。一般说来，新研究计划的发展应以对目标疾病和人群的正式、详细的评估为基础，并以特定于背景和环境的方式进行。考虑到这一战略，儿童急性危重神经系统疾病的患病率：全球流行病学评估(Pangea)小组开展了一项关于急性神经系统疾病的国际点患病率研究，首先发表了主要来自HIC学术医院环境的结果(4)。在接下来的这项研究中，Fink等人(3)提出了在资源有限的环境下(RLSS)患有脑外伤儿童的重要区别，值得进一步关注。与以前的数据一致，在RLS中确定了导致脑外伤的主要原因的关键差异：跌倒是最常见的，在道路交通事故的背景下，行人受害者比乘客受害者更常见(2)。顺便说一句，这些数据也可能有助于预防伤害；具体地说，行人伤害发生率的增加表明，道路改善带来了意想不到的后果，没有预期到需要保护被这些路线吸引的步行通勤者。院前急救不常见(54%)，只有3%由高级生命支持(ALS)培训的提供者运送，51%由基本生命支持(BLS)培训的提供者运送。这种人口评估受到选择偏见的限制，因为儿童只在三级学院医院登记。在RLS中，这可能不包括在送往地区医院时受重伤的儿童，他们无法及时获得交通工具，或寻求治疗被认为是徒劳的。因此，良好结果的高比例(73%)和低报告死亡率(9%)表明，选择可能已经使研究人群偏向于不那么严重的脑外伤。虽然通过BLS或ALS培训的提供者运送的患者在死亡率或良好结局方面没有发现差异，但如果运送的患者患有轻微的脑损伤，并且在转移过程中不需要特定的干预，则可能没有检测到真正的效果。值得注意的是，观察到的脑损伤与感染性脑炎(IE)频率的差异可能受到登记地点的影响。在可能的情况下，患有脑损伤的儿童可能会被转介到第三级护理，而患有IE的儿童可能会被带到最近的医院，并在护理期间留下来。这将是直接被带到转诊中心的IE儿童出现的时间更短的原因。IE的季节性也会改变相对频率(与TBI相比)，特别是由于脑型疟疾。在下一阶段的研究中，地区医疗中心和不同季节的儿童将被纳入…
In low-and middle-income countries (LMICs), the bur-den of unintentional childhood injury is high, with mortality due to injury 3.4 times higher than in high-income countries (HICs)(1). Pediatric traumatic brain injury (TBI) remains a significant global health problem with up to 3 million children affected annually worldwide and mortality rate between 1% and 7%(2). TBI represents one of the most common severe injuries, although inadequately described in the current literature and likely underestimated in LMICs (1). The largest qualitative literature review to date comprised 165,000 children with TBI, yet this population included only 127 children from LMIC (one publication from Africa and three publications from Asia)(2). In this issue of Pediatric Critical Care Medicine, Fink et al (3) partially address the dearth of epidemiologic data available with the aim of informing priorities for future research, education, and quality improvement. Broadly speaking, development of novel research programs should be firmly grounded by a formal, detailed assessment of the target disease and population in a fashion that is specific to context and environment. With this strategy in mind, the Prevalence of Acute critical Neurologic disease in children: a Global Epidemiological Assessment (PANGEA) group undertook an international point prevalence study of acute neurologic disease, first publishing their results predominantly from HIC academic hospital settings (4). In this following study, Fink et al (3) surface important distinctions for children with TBI in resource-limited settings (RLSs) that merit further attention. In keeping with prior data, key differences in the predominant causes of TBI in RLS were identified: falls were the most common and, in the setting of road traffic accidents, pedestrian victims were more common than passenger victims (2). As an aside, injury prevention may also be informed by these data; specifically, increased prevalence of pedestrian injuries suggests an unintended consequence of road improvements that do not anticipate need to protect foot commuters attracted to these routes. Prehospital care was uncommon (54%) with only 3% transported by advanced life support (ALS)–trained providers and 51% by basic life support (BLS)–trained providers. This population assessment is limited by selection bias as children were enrolled only at tertiary academic hospitals. In RLS, this may exclude children who were critically injured at presentation to a district hospital, for whom timely transport was unavailable or for whom seeking treatment was deemed futile. As such, the high proportion of favorable outcome (73%) and low reported mortality (9%) suggest that selection may have biased the study population to less severe TBI. Although no difference in mortality or favorable outcome was detected for patients transported by BLS-or ALS-trained providers, the true effect may not have been detected if the patients transported had mild TBI and did not require specific interventions during transfer.Of note, the observed difference in frequency of TBI versus infectious encephalitis (IE) may have been impacted by the site of enrollment. Where possible, children with TBI would likely be referred for tertiary care, whereas children with IE would likely be brought to the nearest hospital and remain for the duration of care. This would account for the shorter time to presentation of children with IE who were brought directly to the referral center. IE seasonality would also modify the relative frequency (in comparison with TBI), specifically due to cerebral malaria. In the next phase of study, inclusion of children at district healthcare centers and during different seasons would be …